Lecture 9/10 Flashcards
What are the three parts of the preoperative evaluation?
“-Data collection & documentation
- Obtaining a complete problem list
- analysis and discussion of anesthesia management options
- BONUS: presenting this information to the patient”
What should be discussed for anesthesia/surgery preparation?
“-Discuss fasting times for clear fluids and foods
- Discuss which meds to dis/continue and when
- Discuss what new medications the pt will start on”
What medications are continued to the time of surgery?
“-Certain antihypertensives
- Most cardiac meds, including beta blockers
- Systemic glucocorticoids
- Statins
- narcotic pain meds
- MAOIs
- Anxiolytics”
What meds are often held the day of surgery?
“-Insulins
- Hyperglycemic agents (Metformin)
- Diuretics
- High dose ASA and NSAIDS”
Use clinical judgement to determine if the following should be held:
“-ACEI/ARBs
- Long acting insulin
- Low dose ASA
- Antiplatelet agents (ex: plavix/clopidogril)”
What medications have protocols for use pre/during surgery?
“-beta-blockers
-statins
Don’t memorize the protocols”
What type of H&P should you take on a patient? A surgical H&P or an IM H&P?
Both! A good H&P should cover both topics thoroughly. The internal medicine H&P best models the desired level of depth required.
What components make up a pre-op “chief complaint”?
“-What procedure is the pt having?
- When is the surgery happening?
- Give a one-word diagnosis that the surgery is treating.
- Patient status? (Already inpatient? Admitted day of surgery? Admission prior to surgery? Why?)”
What is included in the anesthesia HPI?
“Describe the symptom with the following:
- Where?
- When did this start?
- What major diagnostic tests have been done?
- What aggrivates the problem, how does it affect the pt’s life?”
What do we want from the PMH?
“Detailed description of any non-resolved, chronic, or life-long conditions.
-How’s it treated?
-Pt satisfied w/ degree of control?
-Primary physician satisfied w/ degree of control?
If two of the above are a ““no””, then ask what else can be done, how long it will take, and what specalized interventions are necessary.”
Which organ system received lots of love during the anesthesia pre-op eval?
Cardiovascular
What guidelines should be used for anesthesia care for cardiac issues?
“AHA/ACC guidelines
-Used to evaluate pts (esp w/ CAD and CAD risk)
-Used to evaluate pts for noncardiac surgery
-Used to reduce invasive and threatening procedures on all of our patients
“
What are the four “active cardiac conditions” must be evaluated prior to an elective surgery?
“-Unstable coronary syndromes
-Decompensated CHF
-Significant dysrhythmias (high grade AV block, Mobitz II AV block, third-degree AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias, newly ID’d v-tach, symptomatic bradycardia.
-Severe/poorly compensated valvular disease (severe aortic stenosis, severe mitral stenosis,symptomatic mitral stenosis)
“
Can’t remember the four active cardiac conditions?
-They’re conditions that the pt should be in the hospital (likely in the Critical Care Unit) for.
What is the scale for exercise tolerance that we use?
METs. 1 to >10 is the range; MET=4 means a patient can carry a bag of groceries up the stairs without significant SOB. This ability is enough to allow the patient to have surgery.
Wha are some important questions about exercise tolerance?
“-Did they pass their PT test?
- How often/intense do they exercise?
- Can they carry a bag of groceries up 2-3 flights of stairs w/ minimal or no dyspnea?
- Are they limited? By what?”
What organ system does exercise tolerance measure?
Trick! It can measure any system.
What are the clinical risk factors for a patient?
“Can be subacute or chronic, and may require further limited cardiac evaluation prior to surgery
- H/o heart dz
- H/O compensated or prior heart failure
- History of cerebrovascular dz
- H/o diabetes mellitus
- H/o renal insufficiency (creatinine >/= 2mg/100ml)”
Know the general guidelines of the chart on p 1981
http://circ.ahajournals.org/content/116/17/1971.full.pdf
What do we want for a pulmonary history?
“-previous diagnoses
- any admissions/ER visits
- What meds are they taking?
- Have they ever needed ventilator therapy?
- Have they ever had an episode of acute lung injury (ARDS)?”
What do we want to know about the PSH/past anesthesia history(PAH)?
“-What anesthesia was done?
- Were there complications? What type? What was the outcome? (lasting disability, discomfort, etc)
- Is there anything the pt would have wanted done differently?
- Does the pt have any special concerns/fears/requests for this upcoming procedire?”
What should we ask the pt about OSA?
“-Do they have a confirmed/suspected diagnosis of OSA?
-Do they have a CPAP? Do they use it?
-What is the pt’s Apnea-Hypopnea Index (AHI)?
-Any other treatment measures for this?
If undiagnosed:
-Why suspected? Sleep study scheduled?
-Do they have symptoms of OSA?”
Important transfusion information:
Circumstances, times, and reactions to the transfusion.
What two parts of family history do we want?
General FMH and anesthesia family history.
What allergies are we most concerned about?
Drug allergies and environmental irritants (ex: latex/rubber)
Be sure to ask a thorough medication history!
“-supplements, herbals, prescription, ““once in awhile”” meds, etc.
- have they been advised to hold any meds for this procedure? When and for how long?
- What time of day do they take these meds?”
